One Appendix, Two Different Pains

A previously healthy 27-year-old woman presented with a 1-day history of epigastric pain and nausea. She reported that the pain had migrated from the epigastric area to the lower abdomen. No other associated gastrointestinal symptoms of vomiting, diarrhea, or constipation were described, and she denied the possibility of pregnancy. On arrival, her temperature was 36.8°C, with no other abnormal vital signs. Physical examination revealed tenderness in the left lower quadrant of the abdomen, with maximum tenderness near the umbilicus. Laboratory test results showed a white cell count of 14,000/mm3, with 92.6% neutrophils and no elevations in amylase or lipase levels. On initial evaluation, the Alvarado score for acute appendicitis was 5 of 10, suggesting the possibility of acute appendicitis. However, left lower quadrant pain is an unusual clinical presentation for acute appendicitis. Contrast-enhanced computed tomography (CT) showed an enlarged appendix, 9 mm in diameter at maximum, extending over the spine to the left side of the abdominal cavity  with inflammatory stranding in the surrounding fat. The patient chose a conservative treatment, which led to temporary remission. One month later, however, she developed abdominal pain in the right lower quadrant of the abdomen, and physical examination this time revealed tenderness at McBurney’s point. Abdominal CT revealed inflammation and dilatation of the appendix, which was completely located in the right lower part of the abdominal cavity. A diagnosis of recurrent appendicitis was established. Laparoscopic appendectomy was performed, and the patient recovered uneventfully.

Approximately one third of patients with acute appendicitis develop pain outside the right lower quadrant of the abdomen. Pain in the left lower quadrant is a particularly rare manifestation of acute appendicitis, and most such cases involve congenital abnormalities, including situs inversus totalis and midgut malrotation in which the appendix is located on the left side of the abdomen. Hou et al reported a patient with appendicitis who developed pain in the left lower quadrant and had a long, swollen appendix, with the tip pointing toward the presacral region, just across the midline of the lower abdomen. Yang et al reported a patient with acute appendicitis and left lower quadrant pain who had a redundant, floating ascending colon and inflammatory appendix adhering to the descending colon over the left lower abdomen. These cases and our own suggest that the tip of the appendix can be located in many locations beyond the right lower abdominal cavity, due to causes other than congenital anomalies.

The appendix is considered as a mobile organ that freely wanders inside the abdominal cavity, and its position may not be fixed in a living person. To our knowledge, our case is the first to clearly show that the appendix freely wanders inside the abdominal cavity during a short period. Our case also suggests that the location of abdominal pain for recurrent appendicitis can differ from that for the initial episode of appendicitis. Wherever the pain is, physicians need to consider recurrent appendicitis in patients with abdominal pain who had previously undergone conservative treatment of the initial appendicitis.